Property Owners Proposal Form

Transcription

1 Property Owners Proposal Form PROPERTY PROPOSAL FORM 2015

2 GB Underwriting PROPOSAL FORM: PROPERTY OWNERS This proposal and declaration will form the basis of the insurance contract between you (the proposer) and us. Please answer all questions in full, truthfully and accurately. All material facts* should be disclosed, as failure to do so could invalidate your insurance. *material facts are those facts which are likely to influence insurers in the acceptance of this insurance proposal and it is essential that you disclose them. If you are in any doubt whether a fact is material, you should disclose it, since failure to do so could invalidate your insurance. GENERAL INFORMATION 1. a) Full name, including trading name: b) Full risk address (including postcode): Postcode:... c) Full correspondence address (including postcode): Postcode:... d) Period of insurance: From:... To:... e) i. Occupation and/or use of the property. Please state all trades, using the Additional Information box on page 6 if necessary:.... ii. Do you occupy any part of the property? Yes No If Yes, please provide details:.. iii. Is any part of the property unoccupied? Yes No if Yes, please advise how long the property has been unoccupied, and how long it is anticipated the property will remain unoccupied?. PROPERTY PROPOSAL FORM

3 iv. Is any part of the property used for residential purposes? Yes No if yes, please advise the type of tenant, i.e Professional/Student/DSS/Asylum Seeker etc: f) If there is a bank interest, please provide the name and address: g) Date when business was established:... RISK INFORMATION 2. a) i. Is the property built of brick, stone or concrete and roofed with slate, tiles or concrete? Yes No. ii. Please advise percentage of total roof area that is flat and covered with felt:... % b) Is the property in a good state of repair? Yes No.. c) Approximate age of property:... d) Is the property listed? Yes No If Yes, please provide details including grade: e) i. Is the property undergoing any renovations or are any planned? Yes No If Yes, please provide details: ii. Has any relevant planning permission been obtained? Yes No iii. What is the intended future use?. f) i. Has the property ever been flooded? Yes No ii. Have you been informed that the property is located in a potential flood area? Yes No iii. Is the property within a quarter mile of any river, watercourse or sea? Yes No PROPERTY PROPOSAL FORM

4 If Yes to any of the previous questions, please provide details:. g) Has the property or any adjacent property suffered damage or shown signs of subsidence or heave or displayed any visible signs of cracking? Yes No If Yes, please provide details: h) is the property heated solely by electricity or mains gas? Yes No i) Please provide details of any fire alarm on the property: j) i. Please provide details of any intruder alarm at the property including method of signalling (e.g. Redcare etc.): ii. Has the system been installed by a NACOSS/SSAIB approved installer? Yes No iii. Is the system subject to a regular maintenance contract? Yes No iv. Are all external doors fitted with 5 lever mortice deadlocks conforming to BS3621 or locking bars secured by close shackle padlocks? Yes No v. Is the property secured by roller shutters or grilles, secured by 5 lever close shackle padlocks? Yes No If No to any of the above, please provide details: vi. Are all windows and skylights that are accessible from the ground, fitted with key operated locks or barred or fixed permanently shut? Yes No. vii. Are there any additional security measures at the property such CCTV? Yes No If Yes, please provide details: k. Please provide details of current insurer and renewal date: PROPERTY PROPOSAL FORM

5 COVER REQUIRED 3. a) Standard Perils Fire, Lightning, Explosion & Aircraft? Yes No b) Extended Perils Standard Perils plus Riot, Impact, Storm or Tempest & Flood? Yes No c) Is accidental damage cover required? Yes No d) Is subsidence cover required? Yes No if Yes, please complete a Subsidence Questionnaire. e) Buildings Sum Insured:... f) Landlords Contents Sum Insured:... g) Rental Income (annual):... indemnity Period (12, 18, 24 or 36 months):... h) Property Owners Liability limit of Indemnity: 1,000,000 2,000,000 5,000,000 i) Is Employers Liability cover required? Yes No if Yes, please show the total estimated wages in each catagory for the forthcoming year: Clerical, managerial and supervisory staff:... Caretakers, groundsmen and maintenance staff:... j) Is Terrorism cover required? Yes No CLAIMS INFORMATION Please give details of all losses, whether insured or not or any claims made against the proposer. Date of occurence Brief details of incident Cost/Any amount outstanding PROPERTY PROPOSAL FORM

6 Declaration Has any Insurer or Underwriter cancelled, withdrawn from cover, refused to renew, imposed any special terms or asked the proposer to replace all or part of your insurance? Yes No If Yes, please provide full details: Has any director or partner: a) Ever been convicted of or charged (but not yet tried) with a criminal offence other than a motoring offence? Yes No b) Received an official caution for a criminal offence (other than a motoring offence) within the last 3 years? Yes No c) Ever been declared bankrupt whilst being a director of a company which went into liquidation? Yes No If Yes, to any of the above, please provide full details: Please detail any dealings the proposer has had in the last five years with the Health & Safety Executive, Environmental Health Officer or any other enforcement agency or if you have been the subject of any enforcement measures, prohibition notices or criminal proceedings: I / We declare that the statements and particulars in this proposal form are true and no material facts have been omitted. I / We undertake to inform Underwriters of any material alteration to these facts occurring before completion of the contract of insurance. I / We understand that this proposal, together with any other information supplied, shall form the basis of the contract of insurance. SIGNATURE:... NAME:... POSITION:... DATE:... PROPERTY PROPOSAL FORM

7 Data Protection Act We may store your information and use it for administration, risk assessment, research and statistical purposes, marketing purposes and for crime prevention. We will only disclose your personal details to third parties if it is necessary for the performance of your contract with us. In order to assess the terms of the insurance contract or administer claims that may arise, we will need to collect data that the Data Protection Act defines as sensitive, such as medical history or criminal convictions. By proceeding with this contract you consent to such information being processed by Insurers or their agents. We will keep your information secure at all times. In certain circumstances, for instance for systems administration purposes, we may transfer your information outside the European Economic Area (EEA). By proceeding with this insurance application you consent to us to transfer your information to a country outside the EEA if so required. Should you wish to receive a copy of the information we hold about you, please contact: GB Underwriting Ltd Little Braxted Hall Little Braxted Witham Essex CM8 3EU Additional Information: PROPERTY PROPOSAL FORM

8 GB UNDERWRITING Little Braxted Hall Little Braxted Witham Essex CM8 3EU T F GB Underwriting Limited is an independent underwriting agency which is authorised and regulated by the Financial Conduct Authority. FCA No GB UNDERWRITING 01 Company Registration No GB Underwriting Ltd, Little Braxted Hall, Little Braxted, Witham, Essex, CM8 3EU. KURTZ v6